How Medicare Part A and B claims are processed  (in Original fee-for-service Medicare)

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Overview

Your Medicare Part A and B claims are submitted directly to Medicare by the providers of the service (doctors, hospitals, labs, suppliers, etc.) Note: this section focuses on claims in the original, fee-for-service Medicare program; claims for Medicare Advantage plans (including Medicare HMOs) and Medicare prescription drug benefit plans (Part D) work differently.

Medicare pays Part A claims (inpatient hospital care, inpatient skilled nursing home care, skilled home health care, and hospice care) directly to the facility or agency providing the care. You are responsible for deductibles, co-payments, and any amounts that are considered to be for non-covered services.

Medicare pays Part B claims (doctors' services, outpatient hospital care, outpatient physical and speech therapy, some home health care, ambulance services, medical supplies and equipment, etc.) to either the provider or the patient.

If the provider accepts assignment (agrees to accept Medicare's approved amount as full reimbursement), Part B claims payments are made directly to the provider for 80% of the approved amount. You are responsible for the remaining 20% (your co-insurance).

If the provider does not accept assignment (does not limit the cost of services to Medicare's approved amount), Part B claims payments are made to you. You are then responsible for paying the provider the full Medicare-approved amount, plus up to an additional 15% above the Medicare-approved amount. Note: A provider who accepts Medicare patients can not charge more than 115% of the Medicare approved amount. For more information on ‘assignment’, see our section How medical bills are paid if you have Original fee-for-service Medicare.

It takes about 30 days for Medicare to process a claim.

Medicare will send you an Explanation of Medicare Benefits (EOMB) or Medicare Summary Notice (MSN) form each quarter (every 90 days). The form will state the amount each provider you saw during the quarter is charging (for Part B claims), whether the claim(s) were assigned, how much was approved and paid by Medicare, and how much you still owe.

If you have supplemental insurance, such as a (Medigap) policy or retiree plan

Your supplemental insurance (Medigap) company or retiree plan can receive a claim in one of three ways:

1. Medicare may have an arrangement with the supplemental insurance (Medigap) company or retiree plan to file claims directly with the insurance company. This is called electronic claims processing.
2. If your provider takes Medicare assignment, the provider may submit the claim to your supplemental insurance (Medigap) company or retiree plan.
3. If neither Medicare nor the provider submits the claim, you will need to follow these steps:

• If required, fill out the claim form provided by your insurance company.
• If required, attach copies of the bills you are submitting for payment.
• Attach copies of the EOMB or MSN related to those bills if you have it before the bills are due.
• Make copies of everything for your personal records.
• Mail your claim packet to the insurance company.

Note: Your provider may send you a bill that you may need to pay before you get your quarterly MSN. If so, when you get your MSN, look to see if you paid more than the MSN says is due. If you paid more, call your provider about a refund. If you have any questions about the bill from your provider, call your provider. You can also contact your local Health Insurance Counseling and Advocacy Program (HICAP) for help; 1-800-434-0222.

You will also receive an Explanation of Benefits (EOB) from your insurance company. It will tell you how much was paid. If you haven't heard anything after 30 days, call and ask about the status of your claim.

Calling about claims

Follow these simple steps when you call Medicare, your supplemental (Medigap) insurance company, your retiree plan, or your health care provider to discuss your claims.

1. Identify yourself. Give your Medicare number, your insurance policy number, or your account number from your latest bill.
2. Identify your claim: the type of service, date of service, and the amount of the bill.
3. Ask when your claim will be processed and when you will find out how much has been paid by Medicare or your supplemental insurance carrier (Medigap or retiree plan). Ask your providers if they accepted assignment.
4. Ask how much is still owed and, if necessary, discuss a payment plan.

Be sure to take notes on the date and time of your call, the person you spoke with, and the topics you discussed.

Note about Medicare Advantage plans (such as Medicare HMOs)

If you belong to a Medicare Advantage (MA) plan, you generally won't receive statements from Medicare or have to file claims. MA plans process the paperwork internally. There may be some instances, however, when you receive a statement from Medicare or a bill from a provider. If you have questions or think this is in error, contact your MA plan’s customer service department or call the Health Insurance Counseling and Advocacy Program (HICAP) at 1-800-434-0222 for assistance.

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Page updated April 29, 2008